project: ghana emergency medicine collaborative document title: rapid sequence intubation &...
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Project: Ghana Emergency Medicine Collaborative
Document Title: Rapid Sequence Intubation & Emergency Airway Support in the Pediatric Emergency Department
Author(s): Michele Nypaver (University of Michigan), MD, 2009
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Rapid Sequence Intubation& Emergency Airway Supportin the Pediatric Emergency Dept.
Michele M. Nypaver, MD
UMHS Pediatric Emergency Medicine Fellowship Lecture Series
July 2009
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Objectives
Basics Review The 7 P’s of RSI RSI Pharmacology Procedure Indications/Complications of RSI Advanced Airway options Resources for skill maintenance and help
A is for airway!
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Definitions
Rapid Sequence Intubation:
• Describes a sequential process of preparation, sedation, and paralysis to facilitate safe, emergent tracheal intubation.
• Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform laryngoscopy and tracheal intubation.
• At the same time, careful preparation (including pre-oxygenation) and the use of specific techniques (such as applying cricoid pressure and avoiding positive pressure ventilation) minimize the risks of hypoxia and aspiration.
• Assuming a patient with full stomach. 5
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The Evidence for RSI“NEAR” data: n=156 pediatric intubations
Success Rates for intubation
Sagarin et. al., 2002
METHOD FREQ.
(%)
FIRST ATTEMPT (%) *
FIRST PERSON
(%)
OVERALL
SUCCESS
(%)
COMPLIC-ATION
(%)
RSI 81 78 85 99 1
NO MEDS 13 47 75 97 5
SED, NO NMBA
6 44 89 97 0
* May be due to size and age
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Basic Pediatric Anatomy: Size
Take home point: Small changes in pediatric airways cause large incremental increases in airway resistance
4 mm
8 mm
2 mm
6 mm
NORMAL EDEMA1mm
RESISTANCE(R proportional to 1/(radius^4)
X-SECT AREA
INFANT
ADULT
Increase 16x
Increase 3x
Decrease 75%
Decrease 44%
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23) In this picture taken during DL, the arrow is pointing to which of the following anatomic structure(s)?
a) Arytenoid cartilagesb) Epiglottisc) Valleculad) Vocal cordse) Aryepiglottic fold
PEM BOARD QUESTION!
True Vocal Cords
Pearson Scott Foresman, Wikimedia Commons
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Physical Assessment to identify signs of a real/potential difficult airway in children
Prominent or misshapen occiput short neck poor neck mobility
Facial trauma (including burns) Facial anomalies:
Small mouth Small mandible/recessed chin Abnormal palate Large tongue Loose teeth
Signs of upper airway obstruction hoarseness, stridor, drooling, upright position of
comfort
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Airway Assessment:Malampati & ASA Classification
Malampati Score
UMHS / CES requires documentation of these on all procedural sedation consents10
Hard palate
Pillar
UvulaSoft palate
Jmarchn, Wikimedia Commons
Source Undetermined
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The Lemon Pneumonic
TheCulinaryGeek, Flick
11
Mouth opening > 3 cm
Chin to neck distance > 3 finger breadths
http://archive.ispub.com/journal/the-internet-journal-of-anesthesiology/volume-10-number-1/the-dilemma-of-airway-assessment-and-evaluation.html#sthash.TmMgasnc.dpbs
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RSI Procedures
The 7 “P”s of RSI
PreparationPre-oxygenation/Positioning
Pre-treatmentProtection (Pressure)
PharmacologyPlacement of the tube
Post intubation management
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RSI Timeline/Protocol
Preparation: Zero-10 Min
Monitors, Patient position, Assess for difficulty Equipment and Meds
Pre oxygenate: Zero-5 Min
Pre treat: Zero-3 Min
Time Zero: Inject Paralytic with induction
Protection: Zero-30 seconds
Placement: Zero-45 seconds
Post intubation management: Zero-90 seconds
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http://www.ijciis.org/viewimage.asp?img=IntJCritIllnInjSci_2012_2_3_143_100891_u2.jpg
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Preparation for RSI: Equipment
Type/Size Specific Airway/Difficult Airway Cart
Monitors
Pulse Oximetry CR monitoring CO2 monitoring
References: Broslow Tape, Harriet Lane
Doses Sizing
Personnel
Nurses/Tech’s/Housestaff: Assign roles Walk thru
Prepare for rain!
Molly DG, flickr
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RSI Preparation: Airway equipment for Pediatric patients
Supplemental oxygenNasal cannula (infant, child, and adult)Clear oxygen masks (non-re-breathing - infant, child, and adult)SuctionSuction catheters (6 through 16 French)Yankauer suction tip (two sizes)Bag-mask ventilationMasks (neonate, infant, child, adult)Self-inflating resuscitator bag (450 and 1000 mL)Artificial airwaysOro-pharyngeal airways Intubation equipmentEndotracheal tubes (uncuffed and cuffed, 2.5 through 8.0 mm internal diameter) Stylets (infant, pediatric, and adult) Laryngoscope handle (pediatric and adult) Laryngoscope blades: straight (sizes 0, 1, 2, and 1.5 straight and and curved (sizes 2 and 3) Miller, Mac, Phillips & Wis-HippleRescue airway devicesLaryngeal mask airway (sizes 1, 1.5, 2, 2.5, 3, 4, and 5) Combitube (37 and 41 French)MiscellaneousPulse ox, End-tidal CO2 detector, Magill forceps (pediatric and adult), Bulb suction16
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Endotracheal Tube Sizes
Predicted Size Tube = (Age / 4) + 4
16 + age
4
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Which is the most appropriate equipment and position for the provided patient age?
a) 1 mo: Miller 1 blade, 4.5 uncuffed tube inserted to 14 cm, 8 Fr NG tube
b) 1 mo: Miller 2 blade, 4.5 uncuffed tube inserted to 11 cm, 8 Fr NG tube
c) 3 yo: Miller 1 blade, 4.5 uncuffed tube inserted to 14 cm, 12 Fr NG tube
d) 3 yo: Miller 2 blade, 4.5 uncuffed tube inserted to 11 cm, 12 Fr NG tube
e) 7 yo: Miller 2 blade, 5.5 uncuffed tube inserted to 16 cm, 12 Fr NG tube
PEM BOARD QUESTION!
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Which is the most appropriate equipment and position for the provided patient age?
a) 1 mo: Miller 1 blade, 4.5 uncuffed tube inserted to 14 cm, 8 Fr NG tube
b) 1 mo: Miller 2 blade, 4.5 uncuffed tube inserted to 11 cm, 8 Fr NG tube
c) 3 yo: Miller 1 blade, 4.5 uncuffed tube inserted to 14 cm, 12 Fr NG tube
d) 3 yo: Miller 2 blade, 4.5 uncuffed tube inserted to 11 cm, 12 Fr NG tube
e) 7 yo: Miller 2 blade, 5.5 uncuffed tube inserted to 16 cm, 12 Fr NG tube
PEM BOARD QUESTION!
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14) Which of the following is true regarding laryngoscope blades?
a) Miller blades are designed to sit in the valleculab) Miller blades are available in sizes from neonates to large
adults c) Macintosh blades are used more commonly in
infants/children than in adultsd) Macintosh blades provide a better laryngoscopic viewe) Macintosh blades should not be used to lift the epiglottis
because of increased risk of epiglottic trauma
PEM Board Question!
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14) Which of the following is true regarding laryngoscope blades?
a) Miller blades are designed to sit in the valleculab) Miller blades are available in sizes from neonates to large
adults c) Macintosh blades are used more commonly in
infants/children than in adultsd) Macintosh blades provide a better laryngoscopic viewe) Macintosh blades should not be used to lift the epiglottis
because of increased risk of epiglottic trauma
PEM Board Question!
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RSI: Pre-oxygenation
A critical step Reservoir of oxygen for apnea time Time varies by patient/condition
Begin pre-oxygenation immediately Administer 100% oxygen
If spontaneously breathing: • Non Rebreather Face mask FIO2 100% X 5 min
Avoid bagging sponteously breathing pt If need to bag: Selick maneuver If assisted ventilation or BVM req’d: 8 effective VC breaths provides best pre oxygenation.
Goal: O2 sat > 90% duration of procedure
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Time to desaturation during RSI
Children have a short interval to desaturation
after paralyzation
23Source Undetermined
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RSI Pharmacology: The perfect pharmacologic recipe?
Medical
Trauma (ICP?)
Special Cases
(Asthma)
Mkhmarketing, flickr
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RSI Pre-treatment: Prevent adverse effects of laryngoscopyand /or succinylcholine
Lidocaine Atropine Defasciculation dose of Non depolarizing ?
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RSI Pretreatment: Lidocaine
Local anesthetic
Use in RSI Theory: Blunt rise in ICP (unknown exact mech) No studies available measuring efficacy of lidocaine on
neurologic• Outcome after trauma
Current recommendations 1-2mg/kg IV 2-5 min before intubation Adverse Effects:
Seizure Hypotension
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RSI Pre-treatment: Atropine
Mechanism of Action: Anti cholinergic, Blocks muscarinic ACH receptors
Original Science: Milk introduced in lamb = laryngeal reflex: Apnea, hypoxia and bradycardia Reflex particularly strong in newborn animals and infants
• Wennergren G, Milerad J, Hertzberg T. Laryngeal reflex. • Acta Paediatr Suppl. 1993;389:53–56.
Limited data to answer question: Does atropine prevent bradycardia in children undergoing
RSI?
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Fastle RK Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2004
Oct;20(10):651-5
Does Atropine prevent bradycardia during RSI?
Retrospective cohort study comparing atropine RSI vs no atropine RSI children (0-19y/o)
Rates of bradycardia 4% each group.
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RSI: Atropine?
Myth: Atropine should be administered
before succinylcholinefor neonatal and pediatric
intubation
Bethany Fleming, BA, BS; Maureen McCollough, MD; Sean O. Henderson, MD CJEM. 2005 Mar;7(2):114-7
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Atropine: What can we say?
Who:
All children < 1 year, Children < 5 y/o SCh, AND Prior to repeat dose SCh (in adolescent/adult)
Dose
Current recommendations: AAP ACEP AHA PALS “Cannot recommend uniform guidelines based on lack
of evidence”
• 0.01-0.02mg/kg (min 0.1, max 1.0mg) 1-2 min
• Prior to intubation Adverse effects
Increase HR, Increase IOP
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RSI: Pharmacology/Paralyticwith Induction
Agents determined by condition/scenario
Induction options
Etomidate Midazolam Ketamine Propofol (Currently NOT available in UMHS
ED) Barbiturates Pentothal
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RSI PharmacologyEtomidate
Non narcotic, non barbiturate hypnotic induction Sedative, not analgesic Lowers ICP Pro:
Min CV effects so safe in pts with unstable hemodyn
Dose: 0.3mg/kg IV, onset 2-30 seconds May cause
pain on injection myoclonic jerks hiccups
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RSI PharmacologyEtomidate….but
Adverse Effects
Inhibits mitochondrial hydroxylase activity Even after single dose Effects seen in PICU population
• Implications in septic patients Risk of infection may be increased No randomized clinical trials assess
outcome Bottom line: Using judiciously
Arcadian, Wikimedia Commons
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RSI Pharmacology: BDZ’sMidazolam, Lorazepam, Diazepam
Sedative, anxiolytic, amnestic NOT analgesic
Resp depressants
Reversible with Flumazenil
Several choices
Midazolam: Dose 0.1-0.3mg/kg (induction)
More potent than diazepam
Rapid onset < 1 min
Caution when used with narcotics, esp in younger children/infants
“Near “data suggest many underdose Midazolam!34
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RSI Pharmacology: Ketamine
Dissociative agent; amnestic and analgesia
Release of catecholamine
Increased HR and BP Adverse Effects
Increased secretions Emergence reactions Laryngospasm May increase ICP (relative contraindication)
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RSI Pharmacology: Ketamine
Bronchodilator: intubation of asthmatics
Induction dose: 1-2 mg/kg
Onset 10-15 sec
Duration 10-15 min
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A 12 yo boy with severe asthma is being treated in the ED. So far he has received 2 hours of continuous nebulized albuterol and ipratropium bromide, methylprednisolone and IV magnesium. He is still in severe respiratory distress. A bedside ABG reveals a pH of 7.12, pCO2 80 torr, and pO2 45 torr on 100% supplemental oxygen. You are getting ready to perform rapid sequence intubation (RSI) and preoxygenate with 100% oxygen with a bag/mask system. During induction with ketamine, he develops stridor with suprasternal retractions. Which of the following would be most appropriate?
A) Administer nebulized racemic epinephrineB) Administer IV fentanylC) Administer IV succinylcholineD) Administer IV flumazenilE) Perform jaw thrust until ketamine wears off
PEM Board Question!
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A 12 yo boy with severe asthma is being treated in the ED. So far he has received 2 hours of continuous nebulized albuterol and ipratropium bromide, methylprednisolone and IV magnesium. He is still in severe respiratory distress. A bedside ABG reveals a pH of 7.12, pCO2 80 torr, and pO2 45 torr on 100% supplemental oxygen. You are getting ready to perform rapid sequence intubation (RSI) and preoxygenate with 100% oxygen with a bag/mask system. During induction with ketamine, he develops stridor with suprasternal retractions. Which of the following would be most appropriate?
A) Administer nebulized racemic epinephrineB) Administer IV fentanylC) Administer IV succinylcholineD) Administer IV flumazenilE) Perform jaw thrust until ketamine wears off
PEM Board Question!
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RSI Pharmacology: Propofol
Alkphenol
Sedative hypnotic
Attenuates ICP rise
Dec CPP Induction dose 0.5-1.2mg/kg IV
Adverse problems: BP
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RSI Pharmacology: Thiopental
Barbiturate
GABA receptor
Rapid onset sedation (15 sec)
Decrease ICP
Cardiac depressant, venodilator: Lower BP
Dose: Euvolemic child 5-8mg/kg IV
Hypovolemic child 1-5 mg/kg IV
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RSI: Neuromuscular Blocking
Agents (NMB’s) NMB issues to consider
Documentation of neuro exam Make sure to sedate too Dosing must be adequate Anticipate complications
• Failed intubation• Adverse effects• Prep for surg airway
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RSI Pharmacology: Neuromuscular Blocking Agents (NMB’s) Depolarizing
Succinylcholine* Non depolarizing
Vecuronium Rocuronium Rapacurium Pancuronium Atracurium Curare
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RSI: Neuromuscular Blocking
Agents (NMB’s) Depolarizing Agent (Succ)
Simulate Ach receptors Reliable paralysis with long track record of
use Non depolarizing agents
Competitively block Ach receptors without Stimulating them
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RSI: Neuromuscular Blocking Agents (NMB’s): Succinylcholine
Dose: Infants/Young 2mg/kg IVP
Dose: Older children 1-1.5mg/kg IVP
Contraindications:
Personal/Fam with Malignant Hyperthermia
Burn >10% BSA > 24 hr old (not problem in acute)
Crush injury > 1 week old
Denervation > 1 week old
Progressing/ongoing neuromuscular dz; watch for children with suspected myopathies
Side Effects
Bradycardia (esp after >1 dose); reduced with pre tx with Atropine
Hyperkalemia: Pk 5 min, resolves 15 min, rarely sig
Fasciculations
Myotonic syndromes
MH44
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RSI Pretreatment: Defasciculation?
Prior Recommendations for defasc dose
Non depolarizing NMB before Succ
Enhance effect of succ and reduce side effect
Not routine in peds RSI but some evidence
Of succ induced hyperkalemia.Theroux MC, Rose JB, Iyengar S, et al. Succinylcholine pretreatment using gallamine or mivacuronium during rapid sequence intubation in children: a randomized controlled study. J Clin Anesth 2001; 13:287-292
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In which of the following patients could succinylcholine be used safely for RSI?
a) 2 yo with 2nd and 3rd degree burns covering 20-30% of the body surface area
b) 4 yo in a cervical spine (c-spine) collar with concern for a c-spine injury
c) 12 yo s/p CVA 2 months ago with residual left hemiparesisd) 1 yo with Type 1 spinal muscle atrophye) 17 yo with renal failure on hemodialysis with known
electrolyte abnormalities
PEM BOARD QUESTION!
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In which of the following patients could succinylcholine be used safely for RSI?
a) 2 yo with 2nd and 3rd degree burns covering 20-30% of the body surface area
b) 4 yo in a cervical spine (c-spine) collar with concern for a c-spine injury
c) 12 yo s/p CVA 2 months ago with residual left hemiparesisd) 1 yo with Type 1 spinal muscle atrophye) 17 yo with renal failure on hemodialysis with known
electrolyte abnormalities
PEM BOARD QUESTION!
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Answer: b. Succinylcholine may be used for RSI given its rapid onset and short duration of action. When succinylcholine binds to acetylcholine receptors, potassium is released, increasing serum potassium concentrations. Therefore, it is contraindicated in patients with known/suspected hyperkalemia, including patients with severe burns and those in renal failure (unless potassium is already known to be within normal limits). In patients with neurological denervation, such as would occur s/p CVA, and those with known or suspected myopathies or neuromuscular disease, acetylcholine receptors are upregulated at motor endplates. Therefore with succinylcholine use, massive amounts of potassium can be released precipitating hyperkalemic arrest even in patients with baseline normal potassium levels.
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RSI: Neuromuscular Blocking Agents (NMB’s): Non depolarizingAgents
Competitively block Ach receptor
Does not stimulate receptor
Eventually diffuses out of synapse
Useful for pts who cannot use Succ
Longer duration of action
Onset of action may be a little longer than Succ
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RSI: Neuromuscular Blocking Agents (NMB’s): Non depolarizingAgents
Vecuronium
Dose 0.1-0.2mg/kg/IV Max paralysis: 1-2 min Duration of apnea: 25-45 min Less vagolytic than pancuronium Biliary excretion
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RSI: Neuromuscular Blocking Agents (NMB’s): Non depolarizingAgents
Rocuronium
Dose 1mg/kg
Onset: 60 sec
Duration: Up to 35 min
Little CV effects
Comparison of Rocuronium vs Succ
Equivalent provision of acceptable Int cond. Rates of intubation success similar Succ better at “excellent” condition
AEM 2002 Perry; Metanalysis 1606 pts51
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RSI: Other controversial Succinylcholine Issues
Obese Pts?: Use actual body weight
Is there an optimal dose?
Controversial, Rec peds dose stands
Rose et al. Anesth Analg 2000
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In addition to direct visualization of an endotracheal (ET) tube passing through the vocal cords, the most rapid and reliable means to confirm tube placement in the trachea after intubation is:
A) CapnographyB) Oxygen saturationC) Bilateral breath sounds on auscultationD) Condensation in the ET tubeE) Fiberoptic bronchoscopy
PEM Board Question!
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Difficult airway
King Airway Device
Ochiwar, Wikimedia Commons
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Glidescope
DiverDave, Wikimedia Commons
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Transtracheal Needle Ventilation
Alternative to Cric1) Transtracheal ventilation is difficult.10,11
2) Transtracheal ventilationthrough a catheter must be done with a high pressure,high flow device.10,12
3) Transtracheal ventilation through acatheter cannot be effectively done using a ventilationbag.12
4) The resistance of air flow through a transtrachealventilation catheter increases as a 4th power function as the diameter of the catheter decreases.13
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LMA-Fastrach™
Sizes 3, 4 & 5
Size 3: Children 30-50kg
Airway tube
Handle
LMA FastrachTM ETT Epiglottic Elevating Bar
Cuff
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bigomar2, Wikimedia Commons
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Complications: Anticipate Problems before they happen!
DOPE Displacement Obstruction Pneumothorax Esophageal placement
Medication complications
Take the pt off the vent BVM Check connections/Machines
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RSI Post Intubation Care
Secure the tube
Order the CXR
Administer sedation
Reconsider longer acting paralysis as indicated
Respiratory Care:
Vent settings Respiratory Therapy/transport
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Resources for help/practice
American Heart Association: PALS Manual
UMHS Clinical Simulation Center
UMHS Annual Anesthesia Airway workshop
UMHS PEM Airway Workshop
UMHS Dept of EM Difficult Airway Workshop
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References
Bledsoe GH, Schexnayder SM: Pediatric Rapid Sequence Intubation: A review. Ped Emer Care 20 (5) May 2004
Sagarin MJ. Et al. Rapid Sequence Intubation for pediatric emergency airway management. Ped Emer Care 18(6) Dec 2002
Youngquist S Gausche-Hill. Alternative Devices for Use in Children Requiring Prehospital airway management. Update and Discussion. Ped Emerg Care. 23(4) April 2007
Reed MJ et al. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005 Feb; 22:99-102.
Zelicof-Paul et al. Controversies in rapid sequence intubation in children. Curr Opin Ped 2005, 17,355-362.
Fastle RK et al. Pediatric rapid sequence intubation incidence of reflex bradycardia and effects of pretreatment with atropine. Ped Emerg Care. 2004;20:651-655
Rothrock, SG. Et al. Pediatric rapid sequence intubation incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2005 Sep;21(9):637-8 (Comment regarding 2004 article above).
den Brinker M, Joosten KF, Liem O, et al. Adrenal insufficiency in meningococcal sepsis: bioavailable cortisol levels and impact of interleukin-6 levels and intubation with etomidate on adrenal function and mortality. J Clin Endocrinol Metab. 2005;90:5110-5117.
Zuckerbraun NS et al. Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department. 1: Acad Emerg Med. 2006 Jun;13(6):602-9
Schenarts CL, Burton JH, Riker RR. Adrenocortical dysfunction following etomidate induction in emergency department patients. Acad Emerg Med 2001;8:1-7
. Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000 Feb;16(1):18-21
Cochrane Database of Sytematic Reviews. Rocuronium versus succinylcholine for rapid sequence induction intubation. 2008. Vol 2
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